Provider Demographics
NPI:1306898614
Name:MIKELL, STEPHEN L (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:MIKELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 S AMERICA ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-3529
Mailing Address - Country:US
Mailing Address - Phone:985-705-0349
Mailing Address - Fax:
Practice Address - Street 1:5501 MARVIN SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9007
Practice Address - Country:US
Practice Address - Phone:228-871-4033
Practice Address - Fax:228-871-3344
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.023781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC1488526Medicaid
LA5H178Medicare ID - Type Unspecified
LAC1488526Medicaid